Fitsum Assefa is a nutritionist who recently joined Save the Children, United States (SC/US) as nutrition/food security advisor to the newly established Emergency Response Unit. She has been involved in nutrition and food security programmes in a number of African and Asian countries, mostly in emergencies, and previously worked with MSF-Holland and Concern worldwide.

Kohistan is one of the most remote districts of Faryab Province in Afghanistan. It is in the south of the province bordering Badghis and Ghor provinces and is an eight-hour car journey from the provincial capital of Maimana to the district capital Bandar. The area is normally inaccessible by car for about six months of the year, due to snow and rain. However, the recent mild and dry winters have allowed access for more than eight months each year.

Since 1995, SC/US has run primary health care and women's micro-credit programmes in the four districts that make up the Andkhoy region of the northern part of the province. In the second half of 2000, SC/US initiated drought response activities in northern Afghanistan, primarily in the Andkhoy region. The response included emergency cash loans, cash for work activities and 'complementing' WFP's wheat ration with pulses and oil. In March 2001, SC/US conducted a rapid assessment in southern Faryab. The assessment confirmed the seriousness of the situation in the predominately rain-fed areas. Subsequently, SC/US decided to expand drought response activities into the southern part of Faryab province, co-ordinating closely with WFP-supported wheat distribution activities. SC/US conducted a nutritional survey at the beginning of April.

Background to the Nutritional Survey

Peri-follicular haemorrhage typical of scurvy

The total population of the district is estimated to be 57,630 and is clustered in two main areas.

The district economy is reliant on the production of rain-fed wheat and barley. In the past, the district was self-sufficient in grain and in most years exported to other parts of Afghanistan. Other important agricultural activities in the district include the cultivation of oil crops (mainly sesame), fruits (mainly melons), and fodder crops. Raising sheep, goats and cattle is a very important source of cash as well as food. Oxen are important for traction.

Health services are almost non-existent and there are no doctors working in the whole district. There are only a couple of drug vendors at the district capital, Bandar. There is no routine EPI program and there has never been a measles vaccination campaign. The most common illnesses include diarrhoea, acute respiratory infections, tuberculosis and measles.

Access to drinking water is very poor for most villages in the highland areas. In some villages people (usually women and children) have to walk (up to five hours) up and down the mountains to collect water from the river.

WFP had started food distributions in other more accessible parts of the province. They also attempted a 'once-off' wheat distribution for part of the population in Kohistan in November 2000. However, this was in a location at least 2 days walking distance (one way) from the centre (Ser-e Haus) of neighbouring Pushtunkot district. Only a few people from the surveyed area are thought to have benefited from this distribution, as the cost of time and transport to carry the food was considered to be very high.

From the limited information collected during the earlier rapid assessment (March, 2001), it appears that the drought in the past three years has had a devastating impact on the food and economic security of the district, especially for those dependent on rainfed agriculture. The villages in Lafraye, Mulghee, Khoitoor, Pusiarcha and Sarisang were reported to be the worst affected1.

Though the situation in the whole of Faryab Province, especially Kohistan, has been recognised to be serious, there were no previous comprehensive population-based assessments conducted. Therefore SC/US initiated this survey with a view to assessing nutritional status, food security and mortality.

Methodology of Assessment

SC/US used the standard methodology for a twostage cluster sampling based on a sampling frame of 44 villages. The sampling frame included all the villages in the district that had more than 20 households, were accessible within a maximum of one day walking, and were under government control. A total of 378 households, a population of 3,165, were covered in the survey. Half the survey teams were Afghani women with middle/higher level education. The provincial authorities issued permission both for the overall survey as well as the involvement of women.

The cumulative prevalence for moderate and severe wasting and/or kwashiorkor are illustrated as follows:

Approximately 40% of the severely malnourished were kwashiorkor cases. There was no significant difference found in the prevalence of malnutrition between boys (7.1%) and girls (7.0%), p=0.4. Whilst there is no previous baseline information on the nutritional situation of the district, wasting rates in many parts of rural Afghanistan are normally expected to be around 5%. According to the findings of this survey, 7.0% acute malnutrition did not appear to be a problem of public health significance.

Micronutrient status

Swollen and bleeding gums typical of scurvy

In contrast, the micronutrient status of the population was very poor. A widespread prevalence of vitamin C deficiency disease locally known as "Seialengia" (black legs) was observed during the survey probably complicated with other mineral and vitamin deficiencies. The disease was especially common in Lafraye and Melgee sections. In some of the villages in these sections the deficiency disease is estimated to have affected up to 10% of the population.

The disease affected people of all ages and gender but to a lesser extent children under the age of 2 years. About half of the most severely affected patients were adolescent boys (10 - 18 years) while the elderly were also one of the most affected groups both in terms of frequency and seriousness of the disease. Seialengia mainly affected the poorer families with usually more than one case per family. The incidence of the disease was reported to be higher from mid-December to mid-February. Victims were bed-bound for weeks. Although some people reported that they were showing signs of recovery, none of the affected had completely recovered. Some people who were able to get medicines from drug vendors in Bandar (mainly vitamin C tablets and vitamin B-complex injections) were showing a faster recovery.

In most cases all the signs and symptoms of scurvy,
as described in textbooks, were manifested: blackness
of the legs (indicative of haemorrhage), gum swelling
and bleeding, joint pain and swelling especially of
the knee and ankle joints, backache, pigmentation
and hardness around the hair follicles especially on
the legs (suggestive of failure of the hair follicle
eruption). Most cases had developed hard crust-like
black skin on the knee and ankle joints, reportedly
because they have not been washing for weeks as the
area was too painful to touch, and sometimes resulted
from the herbs they put on them (see picture).

Most Seialengia patients also had angular stomatitis (cracks at the corner of the mouth), swelling and discolouration of the tongue and lack of appetite.

Dietary investigation

Peri-follicular haemorrhage

The consumption of fruits and vegetables by most of the population had been minimal since last summer. The level and severity of the deficiency disease suggests extremely low intake of vitamin C in the winter months. At the beginning of March wild green leaves became available and later other plants. Consumption of these was extensive. Incidence rates in the previous month were declining, suggesting that wild leaves were making a significant contribution. However, the Seialengia cases were hesitant to eat the leaves thinking it would aggravate their problem and/or due to general lack of appetite. The methods used in cooking/processing the wild plants are thought to significantly reduce vitamin C intake from this source. Leaves are cooked for long periods and the water in which it is cooked is not consumed.

In conjunction with the World Health Organisation (using vitamin C tablets provided by WHO), SC/US treated around 250 Seialengia cases with appropriate treatment doses in the 29 cluster villages during the survey.

Food Security and Coping Strategies

Afghani boy with swollen and bleeding gums

According to respondents, before the drought, an average family in Kohistan owned around 15 goats, 25 sheep, 2 oxen, 2 cows and 2 donkeys. As a result of the drought many people had sold most of their animals, dramatically reducing the average family animal ownership to only 1.1 goats, 1.8 sheep, 0.3 cattle/oxen and 0.7 donkeys.

The average number of meals in the previous 24 hours was 2.7 (72.2% of the households consumed three meals while 28.8% reported a recent reduction of meals to two, especially for adults).

It appears that grain stocks from previous years had made a significant contribution in mitigating the impact of the drought, at least in the first two years. Selling livestock was an important coping mechanism employed by most people. At the time of the survey however, there were very few animals left to sell and very few other economic opportunities existed (i.e. selling labour, selling crafts, etc.). People were resorting to 'risky' coping strategies with very low returns such as selling land, displacement, begging and taking loans with high interest rates. The redistribution of resources among relatives was widely practised, but it was not clear for how much longer such support could continue.

According to respondents, extensive labour migration to Iran is not a usual or preferred income source under normal circumstances, as the type of work available is considered physically difficult, degrading (mainly work on construction) and often poorly paid. However, at the time of the survey almost every family in the district had sent at least one man to Iran, and more men were still leaving. Although most men were reported to have left for Iran much earlier, it seemed that the number of men who had left in the last four months (since the start of Ramadan) was significant. The adult population (older than 15 years) female to men ratio has changed from 1.1 before Ramadan to 1.6 at the time of the survey. Of those who had left, none had yet started sending money back. The workers first had to pay back significant loans used to get them to Iran3.

The severe impact of the drought was also
reflected in changes in some cultural and
traditional values. Many villagers reported
that daughters were being given to marriage
at a lower than normal age (about 5% of the
interviewed households were using bride
price as their main source of current
income). The daughters' bride prices have
decreased from the norm of at least $1,800
or up to 100 goats/sheep plus 3-6 cows to
less than $300 or 20 goats/sheep.). Under
normal circumstances, the girl only leaves
her family when the bride price is
completely paid. Currently, some daughters
are being given to their husbands before
payment is completed - it was also reported
that a few families have given their
daughters in marriage for free as they did
not have enough to feed them (though it
was difficult to verify this information). The
other interesting pattern is that men in the
district are not able to afford the bride price
because of the economic crisis. Therefore,
many girls are marrying men from other
parts of the province or country - an
unusual practice4.

Summary of current WHO Guidelines
'Scurvy and its prevention and control in major
emergencies' WHO/UNHCR, 1999

Provisional criteria for determining severity of public
health problem of vitamin C deficiency

In the absence of laboratory facilities the following guidelines may help determine appropriate intervention5.

Severity of public health problem

Indicator

Mild

Moderate

Severe

Clinical signs

?1 clinical case

<1% of population in age group concerned

1-4% of population in age group concerned

?5% of population in age group concerned

Requirements of vitamin C

The daily requirement is estimated at 30mg (FAO,WHO, 1970). For active adult males the daily requirement has been suggested as 40mg due to the relatively rapid turnover of vitamin C and enhanced needs resulting from stress and physical exercise6. With a diet completely lacking in vitamin C, body stores will last approximately 2-3 months. The extent to which scurvy contributes to mortality is uncertain. However, as vitamin C is associated with protection against infection and enhances iron absorption (WHO 1976), deficiency may have a significant impact on mortality especially in this situation in Afghanistan where primary health care facilities are negligible.

Treatment protocol for scurvy

In cases where a population is at high risk of scurvy or where cases of scurvy have already been identified and all the other options for intervention are not immediately feasible, vitamin C supplements need to be considered.

The WHO recommended treatment of scurvy is through the administration 1 g of ascorbic acid daily for 2-3 weeks. Although smaller doses for shorter periods may relieve immediate symptoms and signs, the larger doses and more prolonged treatment are recommended to prevent relapse7. In the longer term, it may be difficult to maintain consumption consistently and coverage may be limited.

Note: Scurvy and its prevention have also been discussed in detail in the following articles in Field Exchange, Issue 5:

Appropriate vitamin C fortification levels for CSB

Micronutrients: the basics

Reduce scurvy risks through germination

Findings/Lessons learnt

Micronutrient deficiencies can occur in the absence of raised levels of malnutrition (as defined by prevalence of wasting).

The pattern of scurvy seems to show that adolescent boys (10-18 years) and the elderly are most affected.

Signs of protein energy malnutrition (wasting) have been a late indicator of the food crisis,

Coping strategies have allowed the population of Kohistan to consume sufficient calories to prevent protein energy malnutrition. However, the diet has lacked sufficient micronutrients to prevent outbreaks of scurvy and other micronutrient deficiencies.

The coping strategies employed have become increasingly desperate and socially disruptive, while at the same time undermining sustainable livelihood patterns. Given the fact that coping strategies are being exhausted, and considering the poor prospect of the next harvest, acute malnutrition could increase rapidly in the near future and/or people will become displaced before they get malnourished. Furthermore, the impact of the coping strategies on long-term livelihoods has not been properly investigated or analysed.

There has been a lack of representative and reliable information, partly due to problems of access to the affected communities due to political and cultural factors. There has also been a lack of coordination and standardised approaches among the different agencies conducting nutrition and food security assessments, limiting the comparability of information between places and over time.

Conclusion

A number of relief workers in Afghanistan have been involved in large-scale nutritional emergencies, mainly feeding centres, clinics etc. in the Horn of Africa. I heard many discussions whereby direct comparison with experiences in the Horn led to the conclusion that the situation in Afghanistan was more or less fine. However, this is a very different situation. The last drought in northern Afghanistan was 30 years ago and lasted for only one year, enabling people to deal with it easily. In contrast, the current drought has lasted 3 years, economic circumstances have deteriorated markedly and people have had to use up all their assets to survive. If such droughts re-occur every decade or so, then it is not inconceivable that an 'Ethiopian highlands' type situation may occur whereby small shocks lead to high levels of malnutrition and mortality as large numbers of people live on the edge of destitution. Responses to this drought should therefore include efforts to prevent this happening.

Recommendations

Recognising the enormous logistical difficulties of reaching the affected population WFP should ensure the provision of wheat and include complementary foods such as pulses, oil and blended/fortified foods for the population. WHO recommends a daily ration of 100g of fortified CSB in order to prevent scurvy in emergency situations.

There is an urgent need to treat scurvy patients, using appropriate WHO recommended dosages of vitamin C.

The response to this situation should include interventions aimed at minimising the long- term risk to livelihoods. Systematic in-depth monitoring of the food/economic security situation, especially use of coping mechanisms should be the key to trigger appropriate responses that are not only directed to saving lives, but also saving livelihoods.

1According to the local population, the district has had three consecutive years of rain/snow failure, which has affected cereal harvests as follows: 50% reduction in 1998, 85% - 90% reduction in 1999, 95% - 100% reduction in 2000. An 80 - 90% reduction is predicted for the 2001 harvest.

2CI= 95% confidence interval with calculated cluster effect.

3(up to $300, with 100% interest rate, compared to the normal cost of only $150)

4Recently the SC/US team encountered a 13 year old girl in Andkhoy district who was "sold" from Kohistan for $120.

5Derived from: Sauberlich et al., 1974, Desenclos JC et al. 1989.

6Olson and Hodges (1987).

7The management of nutrition in major emergencies. WHO, Geneva, 2000.

8Scurvy and its prevention and control in major emergencies, The Micronutrient Series, WHO, 1999.

9See also News piece in this issue on WFP pilot project on fortifying flour with essential micronutrients.